Author reply.

Abstract

well-controlled and psychologically informed treatment contexts can occur safely and mediate subsequent benefits that persist well beyond the day of administration. These treatment ‘highs’ can then be examined through a lens that considers addiction but not exclusively so. We propose that there is value to a broader perspective on the emotional and subjective qualities associated with intoxication – one which acknowledges risk and the prospect of a conceptually novel approach to the varieties of suffering that compel individuals to seek psychiatric care. Psilocybin and MDMA, but not cocaine, seem to support enduring and complex possibilities for self-learning that can be harnessed with psychological interventions. Such data indicate granularity and suggest that positively experienced intoxication is not alone sufficient for therapeutic growth. Similarly, ketamine and its derivatives are not routinely administered in contexts that include psychotherapy, but the combination may facilitate new insights and ways of being for people. Although biological psychiatry has not always concerned itself with these aims, the field is uniquely positioned to help. The ongoing study of medical hallucinogens may at times overestimate their benefits and underestimate their risks, and, for this, scientific integrity is essential. Moreover, not every ‘high’ is therapeutic, and models for hallucinogen use that contribute to experiential avoidance, medication dependence and a diminished sense of agency for patients should be scrutinised. However, a nuanced evaluation of risk and appropriate mitigation strategies can support the development of a new kind of psychiatry. Emerging psychiatric interventions, in our view, should not be condemned merely on the basis that some patients report enjoying the associated subjective effects – an intervention is not ‘bad’ just because it feels ‘good’.